Technically challenging surgery is better for kids

Mayo Clinic surgeons began performing single-incision laparoscopic operations for pediatric intestinal disease in 2010. Today, many gastrointestinal procedures in eligible children are performed through a single, nearly-invisible incision.

Routinely used for appendectomy, cholecystectomy, splenectomy and Nissen fundoplication, single-incision laparoscopic surgery is also becoming the standard of care for children needing intestinal resection for inflammatory bowel disease or polyposis syndromes, according to pediatric surgeon D. Dean Potter Jr., M.D.

"I really don't think twice about it; it's just the way we do it now," he says. "If a patient needs a colectomy, there is no question that I will do it single incision."

Minimal access pediatric surgery was slower to develop than its adult counterpart, in part because the learning curve is steep and smaller instruments are needed. Although children generally have a thinner abdominal wall and less intraabdominal fat than do adults, the limitations of the technique — restricted movement, loss of triangulation and extreme proximity of instruments — are magnified in young patients, making a surgery that is already complex even more technically challenging.

Mayo surgeons have developed approaches that address some of these challenges. One is a radically different technique for performing total colectomy.

"Initially, we mobilized and divided the rectosigmoid colon and dissected from left to right," Dr. Potter explains. "But we now start dissection with the right colon and progress to the rectosigmoid. We found that this simplifies the division of the mesentery and omentum. We've also learned some tricks for dissecting the rectum more easily, even when instruments are in such close proximity."

Dr. Potter and colleagues reported their initial experiences with pediatric single-incision laparoscopic surgery in a recent issue of the Journal of Laparoendoscopic & Advanced Surgical Techniques. They describe a retrospective review of 11 patients, ages 9 to 17, who underwent single-incision laparoscopic procedures at Mayo Clinic in Rochester, Minn., from March 2010 to January 2011.

Surgeries included three total colectomies with end ileostomy, eight ileal-pouch anal anastomosis (IPAA) procedures and one ileocecectomy. They were performed through a single 1- to 1.5-inch (2.5 to 3.8 cm) incision around the umbilicus or ileostomy site using standard instruments. An accessory umbilical port was initially used in six of the procedures.

Operating time was shortest for the ileocecectomy — 168 minutes — and longest for IPAA at 327 minutes. Dr. Potter notes that these times are similar to those generally reported for laparoscopic colorectal surgery.

"Using an accessory port sped things up and eased the transition to a purely single-site surgery, but we rarely need the accessory port any longer — only for complicated resections. The extra port doesn't affect cosmesis, since it's in the umbilicus, and it improves the safety of complex resections," he says.

Outcomes have been encouraging. Initially, patients remained hospitalized for four days, but stays of two or three days are now common, and postoperative narcotic use is minimal, in large part because of the multimodal anesthesia that can be used with single-incision laparoscopic surgery. Most patients resume a normal diet the day after surgery.

"Kids recuperate faster in general," Dr. Potter says, "but one incision is also less painful, so they not only need less pain medication, but they are also less apprehensive and more willing to get out of bed and begin their recovery."

Bowel function for all patients is excellent, with most experiencing about four daily bowel movements. No patient has reported problems with incontinence, but a few have required an extra pad during the night.

Complications and conclusions

In many cases, single-incision colorectal surgery leaves no visible scar.

Five patients experienced postoperative complications, including two anastomotic leaks. Both patients with leaks had diverting ileostomies, which have since been reversed. Other complications included one small bowel obstruction, one pelvic abscess and dehydration. Dr. Potter notes that the overall complication rate is similar to that reported by other groups.

"This is a sick group of patients who are malnourished and require steroids and immunosuppression to treat their disease," he says. "We were very concerned with the two early anastomotic leaks, but we have not had a leak since. We learned that one has to be very selective when considering an IPAA without a diverting ileostomy, whether the surgery is performed through a single incision or via an open technique."

Overall, he says, single-incision laparoscopic colon and rectal surgery has been shown to be safe and effective in children. "When people think of single-incision surgery, they think of no scars, and you certainly achieve that," he says. "You can't even see there has been an incision on the abdomen in many cases. But the real benefit is that children heal faster, have less pain, get out of the hospital sooner and return to normal life more quickly."

Elsewhere at Mayo Clinic

Although Mayo Clinic in Scottsdale, Ariz., and Mayo Clinic in Jacksonville, Fla., do not generally treat patients younger than 18, both are leaders in adult minimally invasive colorectal surgery. In 2009, surgeons at Mayo Clinic in Arizona performed one of the first single-incision laparoscopic total colectomies in the United States, as well as one of the first single-incision proctocolectomies and one of the first single-incision IPAA procedures.

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